Balancing Work, Medication And Mental Illness

With a proper balance of medication and therapy, some people diagnosed with mental illness can succeed in the workplace.

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Originally published on February 28, 2013 6:04 pm

Thirty years ago, when Elyn Saks was diagnosed with schizophrenia, her doctors told her she would never be able to hold a job.

"The idea was that I should lower my expectations," she tells NPR's Neal Conan. "I was advised to be a cashier for a year or two and then think about another job or possibly going back to school."

She didn't listen.

Despite hospitalization, years of psychoanalysis and continued delusions, Saks discovered that work was essential to managing her psychosis. She is now a professor at the University of Southern California Gould School of Law.

"When I'm constructing an argument or responding to an argument and focusing on that, that's where my mind goes, and the kind of crazy stuff recedes to the sidelines," says Saks, who specializes in mental health law. "So it's not one size fits all, and I think it's a mistake prematurely to tell people to lower their sights, lower their expectations."

In a piece for The New York Times, Saks argues that mental illness imposes real limitations, like medication, but says it can also spur creative thinking.

Dr. Richard Friedman, a professor of clinical psychiatry and director of the Psychopharmacology Clinic at Weill Cornell Medical College, says, "Physicians, psychiatrists often have inappropriately low expectations after somebody gets a diagnosis of a serious mental disorder like schizophrenia or bipolar disorder, and settle for function which is much, much lower than the person's actually able to achieve."

He explains that having a social network and a sense of purpose can be just as essential to controlling symptoms as taking medication.

"At the same time," Friedman adds, "I think we should recognize that there probably are a proportion of people who — even with all the encouragement, all the support — may not be able to achieve exactly what they expect or what we think that they should. And we should not push people beyond the point where they're comfortable and capable of actually functioning."

Though Saks still has some symptoms, she says they are not as long-lasting or intense. Finding the right balance of medication was key.

"I think I only really came to terms with having the illness and being careful about how I structured my life, ironically, when I got on really good medication," Saks says. "It made me realize that, you know, these chaotic and violent thoughts weren't things that everybody had."

Saks says the support of friends and family has also been essential to controlling her triggers.

"If I start losing it, my husband and my closest friends usually see what's happening and rally around to try to help me. And I'll talk to my psychiatrist more, and I'll take more medication," she says.

There are times, Saks says, when she's so unwell that she can't work. "Then I just try to lower stimulation in my life, kind of sit in a bare room, listen to quiet music, maybe talk on the phone with friends, but just kind of give myself a bit of a break, a bit of a time to rest and reconstitute."

When actress Glenn Close asked her to be on the board of her nonprofit Bring Change 2 Mind, Close gave her a shirt that says "Schizophrenia."

"And then I thought, 'Do I really want to wear a T-shirt that identifies me as having schizophrenia?' " Saks says.

"And then I thought, 'But people wear bracelets and ribbons and shirts identifying themselves as cancer survivors with pride, without shame, with camaraderie with others.' And we're just not there yet with mental illness."

"The more I admitted that I had a mental illness," she says, "the less it defined me."

Copyright 2013 NPR. To see more, visit http://www.npr.org/.

Transcript

NEAL CONAN, HOST:

This is TALK OF THE NATION. I'm Neal Conan in Washington. Thirty years ago, when Elyn Saks was diagnosed with schizophrenia, her doctors told her to set her sights on a career as a cashier. She didn't listen. Despite hospitalization, years of psychoanalysis and sometimes difficult medication, despite her continued delusions, Elyn finds ways to keep her demons at bay and among the most important is work.

She's now a professor at the University of Southern California's law school. In a piece for the New York Times, she argued that doctors too often tell patients not to expect or pursue fulfilling jobs. She concedes that mental illness imposes real limitations, like medication, but says it can also spur creative thinking.

If this is your story, if you balance work and mental illness, we want to hear from you. Give us a call, 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, Joseph Nye on why the United States isn't and shouldn't contain China and why the Chinese don't see it that way. But first, working with a mental illness, and Elyn Saks joins us now from member station KUSC in Los Angeles. Good to have you on TALK OF THE NATION with us today.

ELYN SAKS: It's great to be on, Neal, thanks so much.

CONAN: And do you remember that younger you who got that diagnosis all those years ago?

SAKS: I do, I do. A lot of people with psychosis have amnesia for their episodes. I've never been so lucky. And I also very much remember how I was approached once I got the diagnosis. So the idea was that I should lower my expectations. I was advised to be a cashier for a year or two and then think about another job or possibly going back to school.

And when I was told that, the thought I had was I've been a student all my life, I love work, I'm good at it, the hours are flexible, it would be so much more stressful for me to have a line of people demanding change. So it's not one-size-fits-all, and I think it's a mistake prematurely to tell people to lower their sights, lower their expectations.

I think we need to give people resources, but with resources, most people, I think, can live up to their pre-illness potential.

CONAN: Most people?

SAKS: That's what I think. That's what I think.

CONAN: Some people would say you're really exceptional, you and other high-functioning schizophrenics.

SAKS: Well, you know, when I was on the lecture circuit after my book, "The Center Cannot Hold," came out, or giving grand rounds or talks, a lot of times people would say that I was really unique, and maybe I wasn't even really schizophrenic. But I suspected that that wasn't really true, and so I undertook to study, quote, high-functioning schizophrenia with Dr. Steve Marder, Amy Cohen and Alison Hamilton and others.

We've got 20 subjects with schizophrenia who are either professionals, full-time students, teachers, heads of nonprofit organizations. So there are others like me out there. It's just that the stigma's so great that people don't come forward. And I understand that.

CONAN: Interesting also that you say work is one of the things that you use to keep those demons at bay.

SAKS: Oh, it's - for me it's the last thing to go, and if I can work, I'm in a good place. So when I'm constructing an argument or responding to an argument and focusing on that, that's where my mind goes, and the kind of crazy stuff recedes to the sidelines. So as I've said, work is both my best - I mean my mind is both my best friend and my worst enemy.

It's really helped me out a lot to have the gratification and the focus and the structure that my work provides me, and I work at a really great law school.

CONAN: Yet there are limitations.

SAKS: There are limitations. For me I think the biggest is I wasn't able to have children. I didn't think I could last through a pregnancy without medication. And I didn't think I could handle the stress of raising children. And it was a big loss for me because I love kids. I really love kids. Fortunately, I have a niece and two nephews, and friends with kids and that kind of thing, but that was a big loss.

CONAN: It was interesting, you said also I think at some point you didn't date for 18 years.

SAKS: Exactly, exactly. I just had too many internal demons and the usual psychological mishegoss that I worked on with my therapist. But I literally went all those years with one or two dates. And then I fell in love, and it's the best thing that ever happened to me.

CONAN: I wonder, when you did that study with the other high-functioning schizophrenics, what about their relationships?

SAKS: You know, some of them had been married, some of them were divorced, and some of them had never married. I think people with schizophrenia are much less likely to marry than people in the general public, but I don't have the exact statistics.

CONAN: It might be another study.

SAKS: I think it is. I think we would like to study people with schizophrenia who have a rich relational life as well.

CONAN: As you went around on that tour, as you meet other people with conditions like yours, more or less, and these are very different kinds of conditions, but people in your situation, there are so many stories of people you hear about who say, you know, I was hospitalized, I may be hospitalized again. How can I start a career?

SAKS: Right, you know, I think you just do the best you can. You, you know, I think you pursue the work that you like, and that's probably going to actually help you rather than hinder you. And if there are down times, you make up for it at other times. I mean people have migraines, or they have other sorts of illnesses that can sometimes impede them working all the time.

But I think with support and with medication and with therapy, people can expect to be able to work.

CONAN: You also talk about managing your triggers. Work is obviously one method you use. What are some of the others?

SAKS: Well, the first thing is if I start losing it, my husband and my closest friends usually see what's happening and rally around to try to help me. And I'll talk to my psychiatrist more, and I'll take more medication. But there are other things, you know, if I can, if I can work, that really helps me. Sometimes I'm so unwell that I can't work. And then I just try to lower stimulation in my life, kind of sit in a bare room, listen to quiet music, maybe talk on the phone with friends, but just kind of give myself a bit of a break, a bit of a time to rest and reconstitute.

CONAN: And these techniques, I think your study found, vary from individual to individual.

SAKS: They do. Some of our people use cognitive devices to challenge their symptoms, and some people were very religious, and some people found - like me, found work really important. So there were all sorts of things that people did. Some people, like me, lower stimulation in their environment. One of our subjects that I mentioned in the Times article puts on loud music to drown out the voices.

So I think everybody has to kind of figure out their own repertoire of techniques they can use to help them get better and stay better.

CONAN: We want to hear from those of you listening today who are struggling with this balance between mental illness and all of its associated difficulties, and work. 800-989-8255. Email talk@npr.org. And let's start with Elizabeth, Elizabeth on the line with us from Chicago.

ELIZABETH: Hello.

CONAN: Hi.

ELIZABETH: Hi, just like your caller, I'm sorry, your guest, I use the same sort of things during my workday to manage my stress. I listen to NPR.

(LAUGHTER)

ELIZABETH: All day. I used to be an employee in the workforce, in offices, and I worked in a very high-stress type of job, and it got to be to the point with my diagnosis of panic and anxiety disorders that I had to actually look for a job that allowed me to work from home, which I am very fortunate I found.

I get to be at home during the day. I don't have to worry anymore about going to an office, about the - like your guest speaks about the social stigma of having these mental illnesses, and it's quite the blessing for me that, again, to the - hospitalizations are a major setback.

I was hospitalized this year, and it was something that I couldn't even discuss with my employer. I had to just explain that I was ill and not what the real illness was. So it's - yes, sir?

CONAN: I think that there are some legal protections, but it's not something you want to tell your employer?

ELIZABETH: Yeah, exactly. It was more of - I guess maybe it comes down to maybe it's still my anxieties, but I - it was something I definitely did not want to discuss with my employer. And while there are legal protections, absolutely, it was not something that I felt like, hey boss, I just was in the cuckoo's nest over here with Jack Nicholson, you know, so...

(LAUGHTER)

SAKS: I mean as you're - you're right, Neal, that there's the Americans With Disabilities Act, which regulates what potential employers can ask you and requires them, if you can, quote, do the essential functions of the job, to give reasonable accommodations to accommodate your disability. So if you need to go to therapy, you know, twice a week during your lunch break, and you're going to be, you know, late, they would need to let you do that and that kind of thing and try to work with your illness so that you can work and manage at the same time.

ELIZABETH: That's excellent to know, thank you.

CONAN: And Elizabeth...

SAKS: Sure. But it does involve disclosing to your employer, and you're right, there are risks to that as well, given stigma.

CONAN: What are the techniques you use to manage your anxieties?

ELIZABETH: Well, fortunately I'm an avid - I love exercising, and that's one thing that my doctor, my - not only my primary care but also my psychiatrist has recommended to me to manage my stress. I've been doing that for years and years and years. And I - it's just one of those things that I can kind of shut my brain off, listen to music and, like, work out the stress, I guess, a little bit.

When I used to work in an office, it was the kind of thing where I would go home at night and worry about my job. I wouldn't sleep because I would worry did I do everything right, did I complete this, is everything going to be OK tomorrow when I go in? And with the job that I have now, I - it's still a 9-to-5, but I'm in this - my house.

I have an excellent job. Like my boss is fantastic, and while we speak every day, it's not like he's breathing down my neck or, you know, like watching to see - he trusts my performance. It's - and I don't have colleagues that are, you know, worried about my business. I'm here by myself, and it just - it works for me. And I am very, very lucky that I have this opportunity to be at home. I've been doing this now for three years.

CONAN: And Elizabeth...

SAKS: And I think the comment "works for me" is really, really critical, and there are different ways you can kind of negotiate the work world if you have a psychiatric illness, and it sounds like, Elizabeth, that you've really been able to do that. I might mention also that some of our subjects mentioned that exercise was one of the things they did to keep themselves sane.

CONAN: And thanks very much for the call, Elizabeth, and we're glad you can join us on the radio.

ELIZABETH: Thank you so much, Neal.

CONAN: We're talking about the situation of those with mental illness and how they cope with the situation of work. If that's your story, give us a call, 800-989-8255. Email us, talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan. Today we're talking with Elyn Saks. She has schizophrenia. Decades ago, when doctors first delivered her diagnosis, they called it grave and told her to limit her professional aspirations. Though the disease has sent her to the hospital, to the pharmacy and into the analyst's chair, she's also successfully made her way into that most rarified of fields, the ivory tower of academe.

Saks is currently a chaired professor at the University of Southern California's law school. She's figured out a variety of techniques that help her and others like her stay on top of the symptoms and focused on the job. If you've been able to balance work and mental illness, we want to hear from you, 800-989-8255. Email talk@npr.org. You can also join the conversation on our website. That's at npr.org, and click on TALK OF THE NATION.

Joining us now is Dr. Richard Friedman, director of the Psychopharmacology Clinic at the Weill Cornell Medical College in New York. He's with us from our bureau in New York. Nice to have you back on the program, doctor.

RICHARD FRIEDMAN: Thanks, Neal, pleasure to be here.

CONAN: And I wanted to ask you, in your practice, yes there are people like Elyn Saks. How many?

FRIEDMAN: Well, as Dr. Saks said, probably very few. And part of the reason is these are individuals who are high-functioning and don't seek out treatment. You know, I want to return to something that Dr. Saks said, which I think is incredibly important, and that is physicians, psychiatrists often have inappropriately low expectations after somebody gets a diagnosis of a serious mental disorder like schizophrenia or bipolar disorder, and settle for function which is much, much lower than the person's actually able to achieve.

And while everybody can't be Dr. Saks, with or without schizophrenia - she's extraordinary, and I'm a big fan of hers - it's still true, exactly what she said. And we know very little about people who are on the higher-functioning end of these illnesses simply because it's ascertainment bias. They never come to us in the first place. They don't seek treatment.

CONAN: Well, she certainly did, and forgive me, Dr. Saks, if I misheard you, but I thought I heard you say most people could do something like you do.

SAKS: Well, no, I think most people with adequate treatment and adequate resources can live up to their pre-illness potential. My colleagues and I, when we designed our high-functioning study, one idea was look at jobs like professional and managerial and so on, and the other was to look at what would have been expected of a person.

So if everybody in your family is a bus driver, and you're a bus driver, that's total success. It's a little bit harder to design a study like that. So I'm not saying everyone can become a professor or a lawyer, but I think a lot of people can do well if we give them help. We just don't step up to the plate and provide the care.

CONAN: This is an email from Grant(ph): My name is Grant from Houston, longtime listener. Listening to your show on my way home, I had to pull over to email in. From 2010 to 2012 I went through a steep downward spiral into depression and anxiety. And of all the medications and therapy I went through, getting a highly demanding job was the number one thing that pulled me out.

Having responsibility and people depending on me gave me a sense of self-worth and brought the light back into my life.

SAKS: Beautifully said, just really beautifully said.

FRIEDMAN: Yes. And underscores how important it is for people to feel useful, productive and socially connected.

SAKS: Exactly, exactly.

FRIEDMAN: I mean, we are social beings. And, you know, you can't expect people to function well in a bubble, and simply giving somebody a medication to control symptoms is inadequate for treating any mental disorder, whether it's schizophrenia or anxiety or depression.

CONAN: But Dr. Friedman, some - a lot of people would say those same medications, at least at times, make it really difficult to function.

FRIEDMAN: Yes, it's a double-edged sword. I mean, all medicines have side effects, and there's a careful balance between the, you know, pros and cons of medication. But in general, I think when they're used correctly and the doses are adjusted, the treatment is far better than the untreated illness.

CONAN: Let's see if we can get another...

SAKS: I spent years - I spent like a decade trying to get off medication and eventually decided to give it a try on it at the encouragement of my psychiatrist. And my life just went so much better. And, sort of, the more I admitted that I had a mental illness, the less it defined me. So I would - I'm, you know, very happy to tolerate the side effects I get for the sake of the well-being that the medicine gives me.

I used to say I don't want to use a crutch. Now I say if my foot were broken, I'd gladly use a crutch. Shouldn't I treat my neurotransmitters as gently?

FRIEDMAN: Of course.

CONAN: Let's see if we can get another caller in. This is Gus(ph) and Gus on the line with us from Green Bay.

GUS: Hi.

CONAN: Hi Gus, go ahead, please.

GUS: Yeah, I just wanted to say that I - my dad suffered from schizophrenia when he was a younger man and then had a long stretch of depression. I've suffered with depression my whole life. But at the same time, I've been able to finish almost three graduate degrees. I've got good - a good run of 20 years as an environmental engineer for a regulatory agency.

And in the last couple of years, what's really helped my life more than treatment, therapy was my involvement with the ManKind Project, which is kind of a nationwide smaller men's group. And that has been really helpful, just talking with other men about what they're going through and finding out that I'm dealing with things as well as I can.

CONAN: As well as you can, that seems to be the operative phrase, Gus, and that seems to be pretty well.

GUS: Yeah, in fact I'm right on the cusp of making a major job change and moving from the Midwest to Arizona to take on an even more challenging job as kind of a manager in a larger nongovernmental organization out there. So I love to challenge myself. I love to do things. It's just for me, a lot of the help I need from therapists and other men is just encouragement, care and friendship and just listening and helping me move along through these little bumps in the road so I don't get down in these low points and stay there.

CONAN: And how much do you tell your employers?

GUS: Not much. I had some actual - I had an issue last year where I was just really having - I don't know if it was a medication issue or what, but I was just really groggy at work and wasn't getting my work done. And I had a new supervisor, and I did have to sit down with him and tell him, you know, I've got - you know, I've got depression, I've got some attention deficit issues, I've also got a sleep apnea issue that I need you to be aware of to help me.

And he actually was very good about helping me, making sure I got the right treatment and, you know, trying to, you know, accommodate me. And so it wasn't...

CONAN: That's really good to hear that there's that sort of flexibility. I wonder, Dr. Friedman, do you - the patients in your experience, do they find their employers that welcoming?

FRIEDMAN: I think it varies by the employer. I mean, he's had a wonderful experience and an understanding employer, but there are just as many that would find, you know, divulging personal information could be potentially stigmatizing and could be harmful. It would be wonderful if, you know, we get to the point where mental illness is treated no differently than any other illness.

After all, the brain is an organ. But it's unfortunately not the case.

CONAN: This email from - go ahead, I'm sorry.

SAKS: Just to circle back to a question earlier and taking off from what Dr. Friedman said, I think that - gosh, I lost what I was going to say. I'm sorry, I lost what I was going to say.

CONAN: That's OK, that's - that's one of my demons. So you can borrow it for this particular moment. Gus, thanks very much for the phone call, and good luck with that move to Arizona.

GUS: You're welcome.

CONAN: All right. Just going back to the point that Dr. Friedman was talking about, this an email from Terry(ph) in St. Louis: I find even when you tell people what you have, they don't totally get it. I also have issues with those that don't believe we fall under the Americans With Disabilities Act. It's a hidden disability. There are still people who think it's your fault.

FRIEDMAN: Yeah, there's a lot of work that needs to be done that, you know, people who have never had the experience of having a serious mental disorder think that these disorders are nothing more than character flaws. It's something so far from the truth, that all someone really needs to do is get a swift kick in the pants and pull themselves up by their own bootstraps. They've never had the experience themselves or had a family member who had mental illness.

But I wanted to return to one other thing that Dr. Saks said, which is that we do often have unrealistically low expectations, but at the same time I think we should recognize that there probably are a proportion of people who, even with all the encouragement, all the support, may not be able to achieve exactly what they expect or what we think that they should.

And we should not push people beyond the point where they're comfortable and capable of actually functioning, that there are some individuals who really do have a very, very serious form of whatever the mental illness is, and we have to accept that they are there, and they exist.

SAKS: I think that's very important, and I should revise what I said and talk about most people, and not everybody...

FRIEDMAN: Right.

SAKS: ...some people, as hard as they try - I wanted to mention another thing about stigma, which is it's possible to internalize it. So Glenn Close invited me to be on her board, Bring Change 2 Mind, and she did public service announcements with T-shirts that said schizophrenia, depression, friend of someone with depression.

And she gave me a shirt that said schizophrenia. And I looked at it, and I thought, I don't wear T-shirts during the week, but I do on weekends. And then I thought, do I really want to wear a T-shirt that identifies me as having schizophrenia?

And then I thought, but people wear bracelets and ribbons and shirts identifying themselves as cancer survivors with pride, without shame, with camaraderie with others. And we're just not there yet with mental illness, and it even affects people, you know, who have the illness.

CONAN: Here's an email that we have: This - my story is about medication. I had to be medicated following brain surgery, and my brain surgeon actually came to work with me one day just to see how I was functioning.

And the listener then asked: How many psychiatrists would do that?

FRIEDMAN: Few.

SAKS: Yeah.

FRIEDMAN: We don't make on-the-site visits. We sort of depend on our patients to tell us how they're doing. An extraordinary doctor.

CONAN: And this is an illustration, though, of another aspect of the problem. A lot of this treatment, a lot of the medication, awfully expensive.

FRIEDMAN: Yes. Huge problem, but that's, you know, the tip of the iceberg with the, you know, mental health care system in the United States, which is, you know, vastly underfunded and has many, many, many problems.

CONAN: Let's see if we can go to another caller. And let's go to - this is Marissa(ph), Marissa with us from Boise.

MARISSA: Hi, Neal.

CONAN: Hi there. Go ahead, please.

MARISSA: Thanks for having me on the show. I listen all the time, and it's actually one of my primary coping mechanisms, like one of your listeners said.

CONAN: One of mine, too, but go ahead.

(LAUGHTER)

MARISSA: I'm actually - I work in the mental health field, but I also have a diagnosis that I received when I was 13. And so it's kind of an interesting dichotomy where it's - it gives me a lot of empathy for my clients. But at the same time, it's an additional stigma with, you know, a fear of, well, does it make me less qualified or more qualified?

My experience has been that the skills that I've learned help me help my clients more effectively, but also the things that I observe and that they teach me help me manage my own symptoms more effectively. And I - in my field, you know, we always say - well, in the medical field, they say: Physician, heal thyself. And a lot of times, I turn that on myself, and I say, you know, use the coping skills you teach your clients.

And it's actually been, I think, the most rewarding thing to work in the mental health field because it does help me be much more empathetic and effective in helping people, because I truly understand what they've gone through and truly understand what they feel. And I think that that's something really unique, and I am fortunate to have the medication and the treatment history that's enabled me to be functional enough to do so.

CONAN: Elyn Saks, one of our earlier callers mentioned exercise. You also mentioned some of your - the people in your high-functioning study were very religious. Diet, another aspect of coping.

SAKS: Yes. A number of our subjects said that that was really important.

CONAN: Not cutting down on what they eat, but what they eat.

SAKS: Right.

CONAN: Healthy diet. Marissa, is that something you take care of?

MARISSA: Absolutely. I mean, one of the big things that I teach my clients - I actually work on a day-to-day basis out in the community with clients to teach how to do basic living skills, how to do symptom management, how to live successful lives through financial employment - all of those things. And one of the first things I always focus on is making sure that they eat, because not eating - low blood sugar can contribute to an escalation of symptoms. And sometimes I have to tell myself that.

CONAN: Well, Marissa, thanks very much for the phone call. Appreciate it.

MARISSA: Thank you.

CONAN: We're talking about dealing with work and mental illness. You're listening to TALK OF THE NATION from NPR News. And let me reintroduce our guests. Elyn Saks, law professor at the University of Southern California, recently wrote "Successful and Schizophrenic" for The New York Times. Also with us, Dr. Richard Friedman, professor of clinical psychiatry and director of the psychopharmacology clinic at the Weill Cornell Medical College in New York.

This is a tweet we have from AddyGoesSwimming(ph): After a boss told me I would have to find my own time for therapy appointments, I quit and found a different job. Should have sued, she says.

So let's see if we go to another caller. This is Simeon(ph), Simeon with us from - it says North America here.

SIMEON: Hi.

CONAN: Go ahead, please.

SIMEON: Hi. This is Simeon. I'm from Rochester, New York.

CONAN: Go ahead.

SIMEON: OK. I'm a rabbi, and I also am bipolar, and the interaction between the two has been sort of fascinating for me, and enriching and, in some ways, kind of tragic. I think, in some ways, being bipolar has served to create a bond of empathy between myself and congregants who, in the past, I've counseled and helped, and it's definitely been something that enables me to connect.

But at the same time, when, as a manifestation of being bipolar, there's anger and other things that come out that are not consistent with my normal personality and people see that, they're confused. They're hurt. They don't understand it. So when that arises, it creates a real sense of betrayal or real confusion.

And the last thing I wanted to say is I think in terms of being successful people with mental illness in a workplace require tremendous support among their bosses. And I think we need to think of the ramp that we build for people who are handicapped as a metaphor.

We build a ramp to help people like that function successfully at work. And we're making a statement that we value you, we think you can contribute productively. Metaphorically, we need to build ramps for people with mental illnesses so that they, too, can have access to the same sorts of opportunities for the benefit of everybody.

CONAN: Sense of betrayal?

SIMEON: What?

CONAN: You talked about a sense of betrayal.

SIMEON: In what...

CONAN: You just mentioned, a moment ago.

SIMEON: You mean as far as people who I was counseling?

CONAN: Yes.

SIMEON: Well, in a sense of - what I meant by that is a sense of - well, a sense of hurt might've been a better word or why, yeah, I guess betrayal's a strong word - but we don't understand and we're confused by this and where is it coming from.

CONAN: Thanks very much for the phone call, we appreciate it. It's a delicate situation.

SIMEON: Yes.

CONAN: We're going to ask Elyn Saks and Dr. Friedman to stay with us as we take another couple of questions after a short break. We're also going to be turning to speak with Joseph Nye about a situation in the East China Sea where a dispute between China and Japan over a group of uninhabited islands is escalating. Stay with us for that. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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CONAN: In a moment, to Joseph Nye and the dispute between China and Japan over some uninhabited islands in the East China Sea and China's concerns about containment by the United States and its allies. But let's continue our conversation on mental illness and the job. Our guests are Professor Elyn Saks, law professor at the University of Southern California; the author, most recently, of "Successful and Schizophrenic" for The New York Times. Her memoir, "The Center Cannot Hold: My Journey Through Madness." Dr. Richard Friedman is also with us, professor of clinical psychiatry and director of the psychopharmacology clinic at the Weill Cornell Medical College in New York. And let's get another caller on the line. This is Shaun. Shaun with us from Austin.

SHAUN: Yes. Hello.

CONAN: Hi. You're on the air. Go ahead, please.

SHAUN: Well, I'm very grateful for this, for hearing this discussion. I'm totally enlightened and feel very validated because I do suffer from depression and fibromyalgia. It's interesting, I heard you discuss your choice between having children and working or, you know, and not having children. I did have children and it's interesting. I've felt very isolated recently, feeling all the things that you guys were discussing of how work can make you not feel that way.

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SHAUN: And so I'm trying to get back into the workforce and feeling very frightened and actually, I feel like I'm putting up my own roadblocks because I am fearful about all of these things you've been discussing.

CONAN: What makes you most afraid?

SHAUN: Not being able to do it. Getting, you know, having - I mean, I've got a Ph.D. I've got a brain but I feel like it's kind of rotting away and I feel like I'm not good enough for anything anymore. I mean, I just don't know what I'd be good at after being 10 years out of the workforce and raising kids. And I just feel like I would get in there and let somebody down or, you know, not have time to go to the doctor, because I go to lots of doctor's visits. And - but at the same time, I'm bankrupting my family because I've got a lot of bills piling up.

FRIEDMAN: Yes, some of the things you're saying, you know, may be part of feeling depressed. You get pessimistic, you get self-doubting and that kind of thing.

SHAUN: Yeah.

FRIEDMAN: I would encourage you to go for it.

SHAUN: Yeah.

FRIEDMAN: I remember what I was going to say earlier which is the question you asked, Neal, that what about someone who can't be at work all the time? They get hospitalized or whatever and I mentioned migraines, but probably a better example would be someone who has vulnerable lungs with asthma or - and gets pneumonia once or twice a year and is out for a couple of weeks. Nobody would think about firing that person. We should treat mental disorders the same.

CONAN: And, Shaun, I would have to say 10 years out of the workforce, just about anybody is going to be concerned whether they can do it anymore, and the only way to find out is go do it.

SHAUN: Yeah. I appreciate that. I guess I'm fearful of making the balance between raising kids, having mental illness and working. I'm fearful that that's just going to be too much. And that you're right, I should just go for it but I guess I'm just really fearful.

CONAN: Well, good luck.

SHAUN: I appreciate this conversation. It's really a wonderful way to cap off my day.

CONAN: Let me thank you, Shaun. And let me end with this email - or this conversation with this email. This is from Julie: I was diagnosed approximately 14 years ago with PTSD, bipolar, dissociative identity disorder. From the beginning, it never crossed my mind I would never work again. I'm an RN and have a master of social work. I'm on disability. I took an RN refresher course back in 2007. All went well. I obtained a full-time job by May 2009. I left work that evening and told myself I'm not going back. I wasn't safe to care for my patients. Thank God I realized it. I could tell I was getting more sick because my days off were consumed by my symptoms. I also have volunteered during my disability. Most recently, a friend helped me to reformulate a resume. I begged my psychiatrist to let me try to go back to work. This time I recognize my limits. I have so much to give back. I just have to find the correct job. Dr. Friedman, recognizing the limits and recognizing when maybe you've bitten off a little bit more than you could chew.

FRIEDMAN: Right. But at the same time, you know, when terrible things happen and people are traumatized, they assume that they'll never be able to return to a place which is highly valuable to them, and sometimes they're wrong. And, you know, in the case of something like post-traumatic stress disorder, it could take many, many, many months of, you know, going back and being exposed. If that's the sort of place and the sort of job that a person wants, then that's a highly valuable endpoint.

CONAN: And Elyn Saks, it's just not - it's also a process of - when you are diagnosed - of learning how - all those coping skills. That can take time too.

SAKS: It can, it can. Certain things work. Certain things don't work. You kind of experiment over time and find what works best for you. That's individual. Different people have different coping skills.

CONAN: How long did it take you?

SAKS: Oh, gosh. You know, the years I spent trying to get off medication, I was in and out of psychosis quite a bit. I'm not that much - I do have some symptoms sometimes still, but not as much and not long - not as long-lasting and not as intense. But I think I only really came to terms with having the illness and being careful about how I structured my life, ironically, when I got on really good medication, because it made me realize that, you know, these chaotic and violent thoughts weren't things that everybody had.

And my mind was clearer, and so it made me realize that I had actually been ill. So I came to terms with that. And you know, having intensive psychoanalytic psychotherapy and work on coping and managing in that and with family and friends as well.

CONAN: Well, thank you so much for sharing your story with us and our listeners.

SAKS: Thank you.

CONAN: Elyn Saks, law professor at the University of Southern California. Our thanks as well to Dr. Richard Friedman at the Weill Cornell Medical College in New York. And Dr. Friedman, good to have you back and thanks very much.

FRIEDMAN: My pleasure. Thank you for having me.

CONAN: In a moment, to the East China Sea. Transcript provided by NPR, Copyright NPR.